Healthcare Provider Details

I. General information

NPI: 1528008711
Provider Name (Legal Business Name): MILTON K WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43971 BOSCELL RD
FREMONT CA
94538-5139
US

IV. Provider business mailing address

43971 BOSCELL RD
FREMONT CA
94538
US

V. Phone/Fax

Practice location:
  • Phone: 570-979-0603
  • Fax: 510-979-0798
Mailing address:
  • Phone: 570-979-0603
  • Fax: 510-979-0798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG52896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: